Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Materi, and we are Ham Therapy Academy.
josh MacDonald: Let's go into everybody's favorite topic. Let's talk about pain scale stuff today and people in, particularly the patients in really high levels of pain sensitivity. um We all probably have an example of a story, probably someone in our clinic right now where everything causes them 10 out 10 pain. They have very large responses to things. Maybe they're in very dramatic pain, but everything causes them pain.
josh MacDonald: But like I've got a clinic, a patient in the clinic right now where when we do any manual stuff on her hands, she's coming in with biocarpal tunnel. But when we do any stuff with her hands, it's very dramatic yelps and wincing and pulling back. And so we backed off of that, but she can do the rice all on her own. No pain problems. She can do towel walking, no pain problems. She can do active stuff, but it's that like,
josh MacDonald: It's that perceived contact touch. Like it's almost like it's a confrontational thing that has her responding to it.
Miranda Materi: Yeah, like a fight or flight response or something.
josh MacDonald: Yeah. Yeah.
Miranda Materi: Yeah, yeah. so
josh MacDonald: Yeah.
Miranda Materi: So what did you do? do do you do you still so i mean, how do you what's her treatment look like? Based on this?
josh MacDonald: So, yeah. So normally for these patients, um and when it's, you know, we say bilateral couple tunnel, that can be a red flag for cervical radiculopathy and upstream stuff. This patient really does have EMG testing that supports bilateral compression median nerves at the wrist level.
josh MacDonald: And so there's all kinds of things we'd love to do manually, but we just don't find that that's effective. Like that pushes her off and so and and takes her down a bad pathway. So instead we found some of the things like nerve glides, And like, you know, maybe the arm pulleys or the foam roller up the wall, walking that up the wall are good for nerve flossing. And then we do a lot of like just gentle hand movement, but all active or maybe some active assisted stuff. So it's all like towel walking and translation with foam cubes, all things she can do with some hesitations in some like, it's not like she's got zero problems, but it doesn't elicit this giant response.
Miranda Materi: Yeah, I think that's great. I think it's like respecting people's sensory responses, right? Some people are hypersensitive to touch and some, you know, like different types of touch and, um, I think being able to modify things and change it is great because I think sometimes as therapists, we think, well, have we really done anything if we haven't done manual therapy?
josh MacDonald: Yeah.
Miranda Materi: And actually, yeah, we're still doing a lot, right? Even though some patients will be like, oh yeah, my traps are really so, you know, like people, some people really want to be touched and it's just the opposite, but it's always like recognizing when that's not therapeutic for the patient.
josh MacDonald: Yeah.
josh MacDonald: Yeah.
josh MacDonald: yeah yeah
Miranda Materi: So with that patient, then are you doing like scar massage or do they do their own scar massage or?
josh MacDonald: um So it's conservative. She hasn't had any surgery. So there's no, so, but for that patient, I might do some of that light vibration input. If there was some scar to manage, I would show her how to do like Dyson. So she wouldn't have to push as hard to get that differential scar movement off the fascial layer.
josh MacDonald: um So there's definitely options where I can give her the tools that's, Hey, that's home program anyway, right? Like that's what she should be doing at home now anyway. So I would definitely give that stuff as part of her treatment plan in the clinic. Yeah.
Miranda Materi: Yeah, I feel like there's so much we don't understand about pain and sensory processing, right?
josh MacDonald: Yeah.
Miranda Materi: So it's just really about what's that patient's unique presentation and just.
josh MacDonald: Yeah. I, I come from a background upbringing, personal, whatever. I come from a background that I really have to fight my inclination that I had with my kids, you know, pick yourself up, dust yourself off, go back and do what you were doing. Like suck it up. What's the big deal. But that's not what these patients are going through. that's, Some patients need a little bit of that tough love to say like, you'll be okay, push through it. it's It's a good kind of, like it's a productive kind of challenge. But for these patients, that's going to have the opposite effect. And I really need to like, hey it it needs a different approach than maybe when my first response would be.
Miranda Materi: Right. And I think that's when it's really good to have multiple therapists and in a room or, you know, treating patients because, you you know, there's some patients, there's some therapists that have, you know, a gift for treating those situations.
Miranda Materi: And there's some, you know, like that maybe would benefit more from like a tough love, like how you would be, right?
josh MacDonald: Yeah.
Miranda Materi: So then it's kind of like, well, I think this patient would do really well with this. They're like, you know, I'm kind of doing that in my clinic thinking when I'm evaluating patient, oh, I'm going to see if this one can go on so-and-so schedule because I feel like they would be a good team together.
josh MacDonald: Yeah, yeah. I learned when I was doing pediatrics, not every therapist and every patient are going to get along and that's okay. You don't, you're not going to be friends with everybody and your style doesn't match everybody and that's okay.
josh MacDonald: But we don't always have the option of handing them off to someone who's maybe, if you're by yourself in the clinic, you have to kind of figure out how am I going to make this situation work? and meet this patient's needs. And maybe I don't need to do manual with this patient. Maybe that's not what they need to get past their limiters and restrictors.
Miranda Materi: Right. And I think there's been a lot of research showing, you know, the patient needs movement, right? And a lot of times they need some type of therapeutic exercise or, you know, stressing those structures a little bit through physical movement. And that has been shown to be just as beneficial as some of the manual stuff that we do.
josh MacDonald: Yeah, yeah. it it So that's all very valuable and important to do. On the flip side of that coin, we have patients who I will watch carry in a Starbucks in one hand and their purse in the other and pull the door open with hands full, set everything down, pull their chair out and say, I'm in a 10 out of 10 pain and can't live my life.
josh MacDonald: and very calmly tell me that everything is a 10 out of 10. And the moment I touch them, they're through the roof, but then I watch them doing all these things. And I think there's a disparity here and it's hard to figure out like,
josh MacDonald: is this like, it's it's not a malingering. It's not like there's, they're not benefiting from saying this. It's not like workers comp is paying them. So that's, you know, they're, they're writing it out, but it's just the disparity that says, how do I get this self to see what this self is capable of doing when you're not aware of what you're able to do?
Miranda Materi: Right. That's true, too. And then what what do you do?
josh MacDonald: Yeah. Yeah. I love giving, ah we, we try to get super creative in our, in our clinics and we try to have a whole bunch of, really quirky, weird, different things because sometimes it's good for patients to not look at whether it's putty or the Dexerciser or the the digit strength tools and it not look like an implement of torture, but hey, these are coins in a bank and this is a book full of buttons and this is some silly little kids game where I'm putting pegs in a thing, but it gets them thinking about this goofy task
josh MacDonald: And then when we're done, we say, look how much you did with your hands. That's fantastic. And so we kind of try to do like a workaround to say like you are capable of a ton. We just have to get you out of the mindset of everything. earth It's almost like a graded motor imagery for the whole body thing.
Miranda Materi: Yeah, that's true. Yeah, that's a good way to use it. Sometimes in our clinic too, we'll be like strategically placing, you know, because our clinic just has like these tables and sometimes it'll be like two people at a table. Sometimes I'm like strategically putting them with someone else.
Miranda Materi: You know, like I know that hearing this person's story is really going to help that other person out, you know?
josh MacDonald: Yeah, yeah, yeah
Miranda Materi: So you do that you too, where you like strategically will put people next to each other because you're like, I think they can benefit from hearing this story.
josh MacDonald: yeah.
Miranda Materi: Or that they had the exact same injury, but this patient was over to overcome it and they're doing so well now.
josh MacDonald: Yeah.
josh MacDonald: Yeah, yeah. There are also times when I will strategically position people far away from each other. Because sometimes...
Miranda Materi: It's
josh MacDonald: Yeah, yeah. I've had patients ask, please don't schedule me at the same time as that person. I just, they're Debbie Downer, i don't want to hear it. Or they kind of like commiserate and spiral out a little bit. And before you know it, they're both down this dark rabbit hole. I'm like, let's split you guys up a little bit next time.
Miranda Materi: about strategic placement.
josh MacDonald: Yes.
Miranda Materi: Yeah.
josh MacDonald: Yes.
Miranda Materi: and like yeah
josh MacDonald: Yeah, for sure. Yeah. yeah So and and I feel like, too, it's how I present things and conversationally out of habit when people walk in. My first thing is, how are you doing today?
josh MacDonald: And and there certain patients for whom I change that question.
Miranda Materi: Thanks.
josh MacDonald: And I'll specifically and I'll tell students, don't ask, how are your hands today or how's your pain today? Like that prompts them to rely on their pain based script.
josh MacDonald: So I ask completely different questions. I ask, did you see your grandkids today? Or over the weekend, did you get all your chores done? Or something very specific to start that conversation in a very natural and organic and genuine way, but something that doesn't lead to that pain script and get us lost down that pathway.
Miranda Materi: Yeah, where you're always focusing on their pain. How you you know how are you having pain today? and I know those questions are, I think, not always great questions. um I like your idea of asking about you know how their grandkids are or if they were doing something over the weekend, you you know remind them of that.
Miranda Materi: And then kind of going down, like of course we wanna know how their hand is doing, but hey, are were you able to do anything new with your hand? Did you you know practice feeding yourself with your hand like we talked about and how'd that go?
Miranda Materi: And ask more questions like that instead.
josh MacDonald: Yeah. Yeah. Yeah. I've got a patient that's in this. She has a horribly stiff hand and it's super quirky and it's hard to figure out. And she's in constant discomfort, but she started golfing and she's like, you know what? I just said, screw it. And went golfing. So we spent the whole time talking about that and didn't get into the pain and discomfort of it at all. I was asking how she shot and, yeah, You know, she could you land in this in the sand at all and and you'll all those questions and get the functional side of it in a positive aspect and not stuck on my hand was really sore afterwards.
josh MacDonald: Good information to know, but let's focus on the positive functional to kind of get them out of that that funk that they're stuck in.
Miranda Materi: Yeah, that negative thought pattern. Because we know our mind is very powerful, right?
josh MacDonald: Yeah. Yeah. Yeah.
Miranda Materi: And we know some people just handle things better than other people.
josh MacDonald: yeah
Miranda Materi: And I think sometimes the the people that are handling it well have kind of trained their minds to think more of in a positive, you know, realm or you know, they've had that mentorship in their life where they've been around positive people.
josh MacDonald: Yeah.
Miranda Materi: And I think it really helps.
josh MacDonald: Yeah. Yeah. And we can be that positive person for them, um not in a manipulative way, but in a let's, you know, let's try to focus more on the positive and maybe that will help decrease the impact of the negative.
Miranda Materi: Right.
Miranda Materi: Yeah, i um I had a patient that fell and was like on a 10 foot ladder and broke his olecranon. He was a, you know, a fairly young guy, like probably late 30s. And he would always come in and be like, I had the most amazing surgery.
Miranda Materi: I'm healing. I'm going to be out of here in no time. Like he would come in and like he had this like mantra he would say every time he came in, he but I'm doing awesome. And it was such a light, but i really think it helped his recovery significantly too.
josh MacDonald: That's great.
josh MacDonald: Oh yeah, absolutely. Yeah. You're right. The mind is a powerful thing and positive self-reinforcement can be ah a huge benefit.
Miranda Materi: Yeah, definitely.
josh MacDonald: Yeah. Yeah. right. Well, patients are not always super simple when we're dealing with pain issues. It can be complicated, but hopefully this helps kind of explain things a little bit and give you some ideas to to help your patient caseload. So if you have any questions, reach out to us on our social media platforms or on our email info at handtherapyacademy.com.
